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Extract

Dr Vinayak1 offers important arguments regarding the minimization of sedation, a trend that has been present in the published literature for more than a decade. However, it is important to look at the practical options for this changing philosophy in sedation strategies. He cites the important study by Strøm et al,2 referred to as “no sedation.” A couple of aspects regarding this study deserve comment. First, patients in this trial who were randomized to the intervention group received morphine, rather than sedatives, as their foundational strategy. Morphine is an opiate analgesic drug. Although not in the category of pharmacologic sedatives, this drug certainly has a “calming” effect on patients who are mechanically ventilated. It is rare that a patient can be managed without any drug, at least not in the early stages of respiratory failure. Second, this study was performed in Denmark, where ICU nursing to patient ratios were universally 1:1. This luxury is very rare in the rest of the world and is certainly a practical limitation to the widespread institution of the “no sedation” strategy. Furthermore, a person who can be summoned to provide verbal reassurance in the event that a patient is agitated is not a reality in most busy ICUs around the world. Last, one of five patients in this study could not tolerate this “no sedation” strategy. Accordingly, this study, although impressive, has important practical limitations. Survival from critical illness is improving substantially. For these reasons, the reality is that sedatives will continue to be necessary for the foreseeable future for managing patients who are mechanically ventilated.

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